Likeness Release Form

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Print the likeness release form

The undersigned hereby irrevocably consents to and authorizes the use by Missouri State University, its officers and employees, ("University") of the undersigned's image, voice and/or likeness as follows: The University shall have the right to photograph, publish, re-publish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or reuse the undersigned's image, voice and/or likeness in connection with any product or service in all markets, media or technology now known or hereafter developed in University's products or services, as long as there is no intent to use the image, voice and/or likeness in a disparaging manner. University may exercise any of these rights itself or through any successors, transferees, licensees, distributors or other parties, commercial or nonprofit. The undersigned acknowledges receipt of good and valuable consideration in exchange for this Release, which may simply be the opportunity to represent the University in its promotional and advertising materials as described above.

Please indicate your agreement to the foregoing by signing below.

Signature _________________________________________________

Print Name _________________________________________________

Address, Telephone _________________________________________________

Date __________________

If you are under seventeen (17) years of age, your parent or guardian must sign below:

I represent that I am a parent/guardian of the minor who has signed the above release and that in that capacity University has my consent and authorization to use the name, voice and/or likeness as described above.